management tasks and skills related to activating resources include communicating with healthcare providers, coordinating services, identifying and benefiting from psychological resources, being part of a spiritual community, obtaining and managing social support, and addressing social or environmental challenges (Schulman-Green et al., 2012).
3) Living with a chronic illness is a self-management process that includes tasks and skills related to coping with the disease and growing as a person, as well as transitioning from a focus on the illness needs to integrating the illness into the context of the individual's life. Four tasks are identified: processing emotions, adjusting, integrating illness into daily life, and meaning-making (Schulman-Green et al., 2012).
In conclusion, the characteristics of self-management are defined in different ways by the objective of practice. Self-management of chronic illness combines the elements of the process, tasks, and skills to encourage them to be active agents in managing their health, which effects on normalizing of the chronic
condition. Most of the self-management definitions, skills, and tasks focus on individual self-management but do not involve family. The researcher realizes the importance of family in supporting and helping patients with chronic diseases to have better self-management behaviors. Therefore, the theory of individual and family self-management of Ryan and Sawin (2009) was used as a guideline for the program's activities among persons with CKD stage 3.
Figure 3 The individual and family self-management theory was modified with the permission of the authors (Ryan & Sawin, 2014).
Self-management is used to manage chronic conditions as well as to engage in health promotion behaviors (Ryan & Sawin, 2009). It is a multidimensional, complex phenomenon that is conceptualized as affecting individuals, dyads, or families across all developmental stages. It includes condition-specific risk and protective factors, the physical and social environment, and the unique characteristics of individuals and family members. Furthermore, it consists of self-management processes, specifically, facilitation of knowledge and beliefs, improvement of self- regulation skills and abilities, and social facilitation. It affects several outcomes, both short and long term (Figure 3).
1. Context dimension
The contextual factors are risks or protective factors that refer to (1) condition-specific factors, (2) physical and social environments, and (3) individual and family characteristics. Condition-specific factors are the physiological, structural,
or functional aspects of the condition, its treatment, or prevention that influence the amount, type, and nature of behaviors required for self-management. Examples of condition-specific factors are the complexity of the condition or treatment, trajectory, physiological stability, or physiological transitions. Environmental factors are
physical or social aspects such as accessibility to health care, the transition from one health care provider or setting to another, transportation, neighbourhood, work, school, culture, or social capital. Individual family factors are those characteristics that affect the individual and family directly (Ryan & Sawin, 2009; 2014).
In the current research, the researchers emphasize family factors, because whether children or adults have a chronic illness, affects the family in every aspect.
Thus, if a person has proper family functioning, it will also positively affect the self- management behavior of those with chronic disease or illness. The family includes parents, siblings, spouse/ partner, and friends, which has a significant potential to influence patients’ chronic illness self-management (Lee et al., 2017). Moreover, the family function has an indirect effect on self-management behavior among persons with early-stage CKD (Photharos et al., 2018). Thus, the engagement of family members (defined here as any family member or friend providing unpaid support for health care) who provide care for a person with chronic disease in the management programs may lead to the improvement of effective patient self- management sustainably.
The models of programs that aim to increase effective family support for chronic illness management and self-care among adult patients should have three domains consisting of 1) Programs that guide family members in setting goals for supporting patient self-care behaviors, leading to improved implementation of family support roles, mixed success, and enhanced patient outcomes. 2) Programs that train the family in supportive communication techniques, such as prompting patients coping techniques or use of autonomy-supportive statements, cause successfully improved patient symptom management and health behaviors. 3) Programs that give families the tools and infrastructure they need to track clinical symptoms and
medications (Rosland & Piette, 2010). Although proper family functioning leads to better self-management behaviors among chronic disease patients, there is a lack of
family involvement during intervention delivery for early-stage CKD (Welch et al., 2015), which needs to be improved in research and practice.
2. Process dimension
The model is influenced by theories of health behavior change, including;
1) self-regulation theory, 2) social support theory, and 3) research related to SM of chronic illnesses. According to this descriptive theory, persons will be more likely to engage in the recommended health behaviors if they have been informed about and embrace health beliefs consistent with their behavior if they develop self-regulation abilities to change their health behaviors, and if they experience social facilitation that positively influences and supports them to engage in preventative health behaviors (Ryan & Sawin, 2009; 2014).
Knowledge and beliefs have an impact on behavior, specifically on self- efficacy, outcome expectancy, and goal congruence. Self-regulation is the process that is used to change health behavior and consists of activities such as goal-setting, self- monitoring, reflective thinking, decision making, planning, self-evaluation, and the management responses associated with health behavior change. Social facilitation includes the concepts of social influence, social support, and negotiated collaboration between individuals, families, and health care professionals. All three processes of self-management were developed as a program to improve the self-management behaviors and clinical outcomes of patients with stage 3 CKD.
Self-regulation is an iterative process that people engage in to achieve changes in health behaviors. Self-regulation comprises skills and abilities including 1) goal setting, 2) self-monitoring and reflective thinking, 3) decision making, 4) planning and action, 5) self-evaluation, and 6) management of responses (Ryan &
Sawin, 2009). Lin et al. (2013) have developed a self-management education program based on self-regulation theory to evaluate its effectiveness on self-efficacy and self- management behavior and CKD progression among patients with early-stage of CKD.
In this single group, pre-test and post-test, repeated-measures, longitudinal study, participants underwent baseline pre-testing (T0) and post-testing at 3 (T1), 6 (T2), and 12 months (T3) after the self-management program was completed. The results showed self-efficacy increased significantly at T2 (χ2 = 8.97, p < .05) and T3
(χ2 = 10.71, p < .05) compared with T0, but it did not improve for self-management behavior. However, eGFR rates remained stable throughout the 12 months.
Self-efficacy is a behavior-specific concept and refers to the degree of an individual’s confidence and ability to successfully engage in behavior in normal and stressful situations (Ryan & Sawin, 2009). Nguyen et al. (2019) conducted a study about the effectiveness of self-management programs in people with CKD stage 3-5 focused on self-management, knowledge, self-efficacy, health-related quality of life, and blood pressure. The intervention was guided by a social cognitive theory and included a face-to-face educational session followed by telephone support. Both groups followed for 16 weeks. At week 16, compared with the control group, large effect sizes for improved self-management, knowledge, and self-efficacy were detected. In terms of health-related quality of life, the physical and mental health components significantly improved. However, there were no significant differences in either systolic or diastolic blood pressures.
Social influence is a message or dialogue in which respected persons in positions of perceived authority with expert knowledge advise and encourage individuals and families to engage in specific health behaviors. These respected persons may be health care providers, family, friends, neighbors, work colleagues, and members of community groups or printed or electronic mediums such as
magazines, television, or the internet (Ryan & Sawin, 2009). Social influence, which is used most frequently, is to encourage and facilitate behavior change through advice and recommendations from medical experts and health professionals, as well as to provide reminders to improve medication or treatment adherence.
Support (emotional, instrumental, or informational) consists of emotional, instrumental, or informational support provided for a person or family with the explicit goal of assisting or facilitating their engagement in health behaviors (Ryan & Sawin, 2009). The mHealth application is an instrument supported by health care providers and widely used for caring for patients with various chronic diseases.
However, there is a lack of understanding of how to use mHealth applications to maintain CKD patients' self-management continuity.
3. Outcome dimension
This theory has proximal and distal outcomes. The proximal outcome is an individual/family's actual engagement in self-management behaviors specific to a condition, risk, or transition, in addition to managing symptoms and pharmacological therapies. The cost associated with health care services is referred to as a proximal outcome. Distal outcomes are related, in part, to the achievement of proximal outcomes.
These outcomes fall into three primary categories: health status, quality of life, or perceived well-being, and cost of health-both direct and indirect (Ryan & Sawin, 2009;
2014). In the current study, the self-management behaviors among persons with stage 3 CKD were measured as a proximal outcome and blood pressure and eGFR were measured as distal outcomes.